Prestigious Personal Home Care Services

Prestigious Personal Home Care Services

APPLICATION FOR EMPLOYMENT
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
SSN
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you legally authorized to work in the United States?

YesNo
Are you at least 18 years old?

YesNo
Active CPR/First Aid Certification:

YesNo
Date Received Certification:
Special skills, certificates, awards or courses:
High School   Type a label
City/State   Type a label
Dates   Type a label

Vocational School   Type a label
City/State   Type a label
Dates   Type a label

College   Type a label
City/State   Type a label
Dates   Type a label

Course(s) of Study   Type a label
Some of our clients speak languages other than English. Are you fluent in any languages other thanEnglish?

YesNo
If Yes (please list)
Do you have any other training, experience, skills, qualifications or experiences which make you especially suited for employment as a senior caregiver?
Any days and times not available to work:
Days and Times you are available to work:
Can you be called at the last minute for emergency assignments:

YesNo
*EMERGENCY CONTACT
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
If applying for a position requiring company driving, do you have a valid Driver’s License?

YesNo
Can you provide proof of current auto insurance?

YesNo
Have you ever been convicted of a criminal offense?

YesNo
If yes, please state the nature of the crime (s), when and where you were convicted, and the disposition of the case:
Other name(s) under which employment may be verified:
Are you able to perform the essential functions of the job for which you are applying, either with orwithout reasonable accommodation?

YesNo
If no, describe the functions that cannot be performed:
WORK EXPERIENCE:
Discuss any training or related experience working with the elderly that you have had:
Company or Employer #1:
Phone Number
Please enter a valid phone number.
Address:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Duties:
Supervisor:
Reason Left:
May we contact:

YesNo
Starting Salary:
Ending Salary:
Company or Employer #2:
Phone Number
Please enter a valid phone number.
Address:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Duties:
Supervisor:
Reason Left:
May we contact:

YesNo
Starting Salary:
Ending Salary:
Personal References
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship:
Known for how many years:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship:
Known for how many years:
CERTIFICATION AND RELEASE

I certify that I have read and understand the application note onpage one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicledriving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Signature

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Date

MonthDayYear
Date
NOTICE REGARDING BACKGROUND INVESTIGATION
A consumer report (background screening report) and/or an investigative consumer report which may include information obtained through personal interviews concerning your character, employment history, general reputation, personal characteristics, police records, education, qualifications, motor vehicle record, mode of living, and credit and indebtedness (can be removed if never seeking credit reports) may be obtained in connection with your application for and/or continued employment, contract for services or volunteer services with Prestigious Personal Home Care Services Inc.A consumer report and/or an investigative consumer report may be made any time during the hiring or renewal process and/or during your employment, contract for services or volunteer services with the Prestigious Personal Home Care Service Inc. You have the right, upon written request made within a reasonable time after receipt of notice, to request disclosure of the nature and scope of any consumer report or investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation conducted by a third party of employment history conducted by Safe Hiring Solutions LLC, P.O. Box 186, Crawfordsville, IN 47933 888-215-8296.
AUTHORIZATION
By signing below, I hereby voluntarily authorize Prestigious Personal Home Care Services Inc. to obtain either a consumer report or an investigative consumer report about me from a consumer reporting agency and to consider this information when making decisions regarding my employment, contract for services, or volunteer services at Prestigious Personal Home Care Service Inc.I understand that I have rights under the Fair Credit Reporting Act, including the right to dispute the accuracy of information contained in the consumer report.I understand that any information contained in the consumer report may be used to deny employment, contract for services, or volunteer opportunities. I understand that I will be provided with a copy of the Fair Credit Reporting Act, including a Summary of Rights under the FCRA. This report may be delivered in either written or electronic form.
Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Last 4 of S.S.N
Driver’s License Number:
Driver’s License State:
Any other names I have been known by:
Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address (Last 7 Years):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check for CA, MN or OK applicants only, if you would like to receive a copy of the consumer report if one is obtained.

YesNo
Should be Empty:

Prestigious Personal Home Care Services

*EMERGENCY CONTACT

WORK EXPERIENCE:

Personal References

CERTIFICATION AND RELEASE

NOTICE REGARDING BACKGROUND INVESTIGATION

AUTHORIZATION